Biomedical subjects

Vimla L Patel

Publications and source records attributed to Vimla L Patel.

At least 55 records · Page 3Linked to original sources

PubMed2003

The classification of clinicians' information needs while using a clinical information system.

INTRODUCTION: Information needs are prevalent in clinical practice. They represent a potential source of medical errors. This study seeks to empirically determine the information needs of clinicians while using a clinical information system (CIS), and characterize those needs. In addition this paper will provide the framework necessary for the development of the solutions to these information needs. METHODS: Clinicians were observed while using a CIS. They were recorded on audiotape and the computer screen recorded on videotape. The types of question during these interactions were recorded. A classification of the questions provided the conceptual and architectural basis for the development of context-sensitive links to information resources, called infobuttons. RESULTS: There were 154 information needs. The questions were grouped into seven categories. Within these categories we were able to identify eleven specific repeated question patterns, accounting for 72 or 47% of users' questions. DISCUSSION: These findings are applicable to a number of settings and can be generalized to other institutions. The proposed infobuttons based on six categories, will be navigational ('how-to.' links), cross-reference ('what is the em leader ' links), domain knowledge buttons in the areas of laboratory, pharmacy, diagnosis, and definitions/general information. Using these groups we were able to identity eleven patterns of questions.

Clinical Medicine↗

PubMed2003

An extended hierarchical task analysis for error prediction in medical devices.

This paper introduces an extended hierarchical task analysis (HTA) methodology devised to evaluate and compare user interfaces on volumetric infusion pumps. The pumps were studied along the dimensions of overall usability and propensity for generating human error. With HTA as our framework, we analyzed six pumps on a variety of common tasks using Norman's Action theory. The introduced method of evaluation divides the problem space between the external world of the device interface and the user's internal cognitive world, allowing for predictions of potential user errors at the human-device level. In this paper, one detailed analysis is provided as an example, comparing two different pumps on two separate tasks. The results demonstrate the inherent variation, often the cause of usage errors, found with infusion pumps being used in hospitals today. The reported methodology is a useful tool for evaluating human performance and predicting potential user errors with infusion pumps and other simple medical devices.

Ergonomics↗

PubMed2003

Use of online resources while using a clinical information system.

BACKGROUND: Clinical information system (CIS) use is likely to evoke information needs, yet information resources use during CIS use has not been studied. METHODS: We used CIS log files and a survey to characterize clinicians' use of resources and infobuttons (context-sensitive links from a CIS to specific resources) while using a CIS. RESULTS: We examined 38,763 uses of resources and infobuttons by 2,607 users to identify specific sources and contexts (CIS functions) in which they used them. Laboratory results review was the most frequent context and Micromedex was the most popular resource. Differences in resource use were related to context and user type. The survey confirmed that resources and infobuttons were perceived as useful for patient-specific questions while using a CIS. CONCLUSIONS: Understanding context- and user-type-specific information needs can guide the development of infobuttons for use in a CIS.

Clinical Laboratory Techniques↗

PubMed2003

The cognitive complexity of a provider order entry interface.

Computer-based provider order entry (POE) can reduce the frequency of preventable medical errors. However, overly complex interfaces frequently pose a challenge to users and impede clinical efficacy. We present a cognitive analysis of clinician interaction with a commercial POE system. Our investigation was informed by the distributed resources model, a novel approach designed to describe the dimensions of user interfaces that introduce unnecessary cognitive complexity. This approach characterizes the relative distribution of user's internal representations and external representations embodied in the system or environmental artifacts. The research consisted of two component analyses: a modified cognitive walkthrough evaluation and a simulated clinical ordering task performed by seven physicians. The analysis revealed that the configuration of resources placed unnecessarily heavy cognitive demands on the user, especially those who lacked a robust conceptual model of the system. The resources model was also used to account for patterns of errors produced by clinicians.

Cognition↗

PubMed2003

A cognitive framework for understanding barriers to the productive use of a diabetes home telemedicine system.

Telemedicine has the potential to transcend geographic and socio-cultural barriers to the delivery of high quality health care to the medically underserved populations. However, there are significant cognitive and usability barriers. This paper presents a multifaceted cognitive evaluation of the IDEATel diabetes education and telemedicine program. The evaluation included a cognitive walkthrough analysis to characterize task complexity and identify potential problems as well as field usability testing in patients' homes. The study revealed dimensions of the interface that impeded optimal access to system resources. In addition, we found significant obstacles corresponding to perceptual-motoric skills, mental models of the system, and health literacy. The objective of this work is to contribute to a design framework so that participants with a wide range of skills can better manage their chronic illnesses.

Aged↗

PubMed2003

Specifying design criteria for electronic medical record interface using cognitive framework.

As the healthcare industry transitions from paper to electronic medical records (EMRs), medical informatics researchers face the task of ensuring that the electronic presentation of the information remains usable and effective while capitalizing on the ability of EMRs to tailor information to different users. In our research, we focus on utilizing formal cognitive science methodology to guide the conversion of paper-based narrative discharge summaries to a more dynamic, structured electronic version. In this paper, we present the results of a cognitive analytic study (1) that determines a 'core' component in medical narratives and (2) that compares the use of structured and narrative texts by physicians with varying expertise. Specifically, we studied six psychiatrists at three levels of expertise- experts, intermediates, and novices. The subjects were given two clinical case scenarios with discharge summaries and asked to verbalize their thoughts as they read through the summaries. The interview transcripts were analyzed for recalls and inferences generated in the verbalization. Based on experts' verbalizations, the discharge summaries were organized into a more structured form and used in the interview of other subjects. Novice-level subjects had more recall with the structured than with the narrative format. More errors were also made in recall with the narrative than with the structured text. We discuss how these results are valuable in designing an EMR interface to reduce errors and to support users of different expertise.

Cognition↗

PubMed2003

GESDOR - a generic execution model for sharing of computer-interpretable clinical practice guidelines.

We developed the Guideline Execution by Semantic Decomposition of Representation (GESDOR) model to share guidelines encoded in different formats at the execution level. For this purpose, we extracted a set of generalized guideline execution tasks from the existing guideline representation models. We then created the mappings between specific guideline representation models and the set of the common guideline execution tasks. Finally, we developed a generic task-scheduling model to harmonize the existing approaches to guideline task scheduling. The evaluation has shown that the GESDOR model can be used for the effective execution of guidelines encoded in different formats, and thus realizes guideline sharing at the execution level.

Decision Making, Computer-Assisted↗

PubMed2003

Automated identification of shortcuts to patient data for a wireless handheld clinical information system.

Inadequate access to patient information at the point of care has been identified as an impediment to the health care process. To create clinical computing tools that are useful to and used by clinicians, developers of clinical information systems must have accurate models of the users for whom their systems are intended. To create these models, the information needs of clinicians must be understood. While the wireless handheld environment offers many advantages such as the ability to provide mobile access to information, there are a number of challenges. Developing for this environment differs from the laptop and desktop environments due to features such as processing power, screen size, input mechanism, and bandwidth. PalmCIS (Palm-based Clinical Information System) is a clinical application being developed at New York Presbyterian Hospital (NYPH) that provides clinicians with access to patient data via a wireless handheld device. We are using an automated technique to uncover patient-specific information needs of clinicians while using a patient record system. With the results, we can enhance PalmCIS.

Computers, Handheld↗

PubMed2002

Representation primitives, process models and patient data in computer-interpretable clinical practice guidelines: a literature review of guideline representation models.

Representation of clinical practice guidelines in a computer-interpretable format is a critical issue for guideline development, implementation, and evaluation. We studied 11 types of guideline representation models that can be used to encode guidelines in computer-interpretable formats. We have consistently found in all reviewed models that primitives for representation of actions and decisions are necessary components of a guideline representation model. Patient states and execution states are important concepts that closely relate to each other. Scheduling constraints on representation primitives can be modeled as sequences, concurrences, alternatives, and loops in a guideline's application process. Nesting of guidelines provides multiple views to a guideline with different granularities. Integration of guidelines with electronic medical records can be facilitated by the introduction of a formal model for patient data. Data collection, decision, patient state, and intervention constitute four basic types of primitives in a guideline's logic flow. Decisions clarify our understanding on a patient's clinical state, while interventions lead to the change from one patient state to another.

Artificial Intelligence↗

PubMed2002

The patient clinical information system (PatCIS): technical solutions for and experience with giving patients access to their electronic medical records.

As health records evolve into electronic form, increasing demand is being made to provide patients with access to them. We sought to study the character and impact of such access to determine how patients use such records, what cognitive effects it has on them, and how it affects their relationship with their health care providers. We created the Patient Clinical Information System (PatCIS) to interface with the clinical data repository at New York Presbyterian Hospital (NYPH) to allow patients to add to and review their medical data. We also provided educational resources and automated advice programs. We provided access to the system to thirteen subjects over a 36-month period and reviewed their activities in the system's usage log. We also collected data via questionnaire and telephone interview. We collected data for a total of 223 patient months. We found that patients varied in their use of the system, from once a month or less to one or more times per day. All patients primarily used the system to review laboratory results. Both they and their physicians believed that use of the system enhanced the patients' understanding of their conditions and improved their communication with their physicians. There were no adverse events encountered during the study.

Adult↗

PubMed2002

Errors in interpreting quantities as procedures: the case of pharmaceutical labels.

The purpose of this study is to investigate and characterize the errors in cognitive processes deployed in the comprehension of procedural texts found on pharmaceutical labels by subjects of different cultural and educational backgrounds. In this study, participants were asked to read and interpret three pharmaceutical labels related to children's medications of varying complexity: oral rehydration therapy (ORT); over-the-counter cough medicine; and over-the-counter fever medicine. Results indicate that: (1) all groups of participants had considerable difficulty in interpreting the instructions; (2), cultural and educational background appeared to be only weakly related to the accuracy of dosage and administration; and (3) errors of comprehension were related to three features of the texts: situation-representational complexity, inherent quantification complexity, and conformity with intuitive models of therapy based on prior knowledge. The results are discussed in terms of the role of multiple representations (boundary objects) and theories of text comprehension to facilitate the reduction of errors.

Adult↗

PubMed2002

Patients' and physicians' understanding of health and biomedical concepts: relationship to the design of EMR systems.

OBJECTIVE: The aim of this paper is to examine knowledge organization and reasoning strategies involved in physician-patient communication and to consider how these are affected by the use of computer tools, in particular, electronic medical record (EMR) systems. DESIGN: In the first part of the paper, we summarize results from a study in which patients were interviewed before their interactions with physicians and where physician-patient interactions were recorded and analyzed to evaluate patients' and physicians' understanding of the patient problem. We give a detailed presentation of one of such interaction, with characterizations of physician and patient models. In a second set of studies, the contents of both paper and EMRs were compared and in addition, physician-patient interactions (involving the use of EMR technology) were video recorded and analyzed to assess physicians' information gathering and knowledge organization for medical decision-making. RESULTS: Physicians explained the patient problems in terms of causal pathophysiological knowledge underlying the disease (disease model), whereas patients explained them in terms of narrative structures of illness (illness model). The data-driven nature of the traditional physician-patient interaction allows physicians to capture the temporal flow of events and to document key aspects of the patients' narratives. Use of electronic medical records was found to influence the way patient data were gathered, resulting in information loss and disruption of temporal sequence of events in assessing patient problem. CONCLUSIONS: The physician-patient interview allows physicians to capture crucial aspects of the patient's illness model, which are necessary for understanding the problem from the patients' perspective. Use of computer-based patient record technology may lead to a loss of this relevant information. As a consequence, designers of such systems should take into account information relevant to the patient comprehension of medical problems, which will influence their compliance.

Cognition↗

PubMed2002

Emerging paradigms of cognition in medical decision-making.

The limitations of the classical or traditional paradigm of decision research are increasingly apparent, even though there has been a substantial body of empirical research on medical decision-making over the past 40 years. As decision-support technology continues to proliferate in medical settings, it is imperative that "basic science" decision research develop a broader-based and more valid foundation for the study of medical decision-making as it occurs in the natural setting. This paper critically reviews both traditional and recent approaches to medical decision making, considering the integration of problem-solving and decision-making research paradigms, the role of conceptual knowledge in decision-making, and the emerging paradigm of naturalistic decision-making. We also provide an examination of technology-mediated decision-making. Expanding the scope of decision research will better enable us to understand optimal decision processes, suitable coping mechanisms under suboptimal conditions, the development of expertise in decision-making, and ways in which decision-support technology can successfully mediate decision processes.

Cognitive Science↗

PubMed2002

Theoretical, empirical and practical approaches to resolving the unmet information needs of clinical information system users.

We hypothesize that when clinicians review clinical data in an electronic medical record, the information needs that arise are predictable, based on a number of situational factors. Because our theory does not say, exactly, what those needs are, we are using an empirical approach (observation) to detecting and categorizing them. For each need, we can construct an "infobutton" that links the clinical data to an on-line information resource. We have constructed an Infobutton Manager to match the data being reviewed by clinicians with context-appropriate infobuttons. This paper describes how the theory, observations, and practical solutions can come together to improve clinician decision making by resolving information needs.

Decision Making, Computer-Assisted↗

PubMed2002

Web-based tailoring and its effect on self-efficacy: results from the MI-HEART randomized controlled trial.

This paper reports the effects of a tailored Web-based delivery system on self-efficacy as it relates to a patients' response to acute myocardial information (AMI) symptoms. The data reported are from MI-HEART, a randomized trial examining ways in which a clinical information system can favorably influence the appropriateness and rapidity of decision-making in patients suffering from symptoms of acute myocardial infarction. Participants were randomized into one of three groups: tailored Web-based, non-tailored Web-based and non-tailored paper based. A theoretically based behavioral-cognitive model was used to identify key variables upon which to tailor education material. A key variable in the model is self-efficacy, operationalized with a three-dimensional scaling. Results show trends in improved self-efficacy scores for all groups at 1-month follow up, with sustained significant increases in baseline to 3-month scores only in the tailored Web-based group. One possible explanation could be related to "hit-count", which was significantly higher in the tailored group. This study is a first step in quantifying the contribution of Web-based tailoring over non-tailoring in changing key determinants of patient delay to AMI symptoms.

Algorithms↗

PubMed2002

Support for guideline development through error classification and constraint checking.

Clinical guidelines aim to eliminate clinician errors, reduce practice variation, and promote best medical practices. Computer-interpretable guidelines (CIGs) can deliver patient-specific advice during clinical encounters, which makes them more likely to affect clinician behavior than narrative guidelines. To reduce the number of errors that are introduced while developing narrative guidelines and CIGs, we studied the process used by the ACP-ASIM to develop clinical algorithms from narrative guidelines. We analyzed how changes progressed between subsequent versions of an algorithm and between a narrative guideline and its derived clinical algorithm. We recommend procedures that could limit the number of errors produced when generating clinical algorithms. In addition, we developed a tool for authoring CIGs in GLIF3 format and validating their syntax, data type matches, cardinality constraints, and structural integrity constraints. We used this tool to author guidelines and to check them for errors.

Algorithms↗

PubMed2002

Toward a cognitive taxonomy of medical errors.

One critical step in addressing and resolving the problems associated with human errors is the development of a cognitive taxonomy of such errors. In the case of errors, such a taxonomy may be developed (1) to categorize all types of errors along cognitive dimensions, (2) to associate each type of error with a specific underlying cognitive mechanism, (3) to explain why, and even predict when and where, a specific error will occur, and (4) to generate intervention strategies for each type of error. Based on Reason's (1992) definition of human errors and Norman's (1986) cognitive theory of human action, we have developed a preliminary action-based cognitive taxonomy of errors that largely satisfies these four criteria in the domain of medicine. We discuss initial steps for applying this taxonomy to develop an online medical error reporting system that not only categorizes errors but also identifies problems and generates solutions.

Cognition↗

PubMedDate not supplied

Mining complex clinical data for patient safety research: a framework for event discovery.

Successfully addressing patient safety requires detecting medical events effectively. Given the volume of patients seen at medical centers, detecting events automatically from data that are already available electronically would greatly facilitate patient safety work. We have created a framework for electronic detection. Key steps include: selecting target events, assessing what information is available electronically, transforming raw data such as narrative notes into a coded format, querying the transformed data, verifying the accuracy of event detection, characterizing the events using systems and cognitive approaches, and using what is learned to improve detection.

Database Management Systems↗